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Feature Quality improvement

Patient safety lessons from the world’s experts

BMJ 2018; 363 doi: (Published 27 December 2018) Cite this as: BMJ 2018;363:k5211

The hidden patient safety problem

The hidden patient safety problem

To the Editor,
While the valuable points raised in the report are targeting the heart of patient safety and remind us of the importance of building safety into the system and developing a transparent culture of safety, thinking about potential hazards before they become adverse events, and the role of leadership in facilitating the implementation of policies, little is discussed about medication errors in community pharmacies.1

We can see that most policies and regulations about patient safety are targeting initiatives to reduce hospital related errors and ensuring safety of patients in the inpatient settings, and little effort has been made in the settings outside the hospital particularly in relation to medication errors in the community.2 Considering the progressive increase in pharmacy visits and the number of medications dispensed annually, one could realize the size of such problem.3

Searching the literature, we find relatively few studies about errors in medications dispensed by community pharmacists, in the meantime there are limited or no policies in some countries about management and report of medication errors.4 The problem gets worse in countries were medications could be supplied by pharmacists to patients and their relatives without a prescription; how these errors could be traced, managed or reported will definitely not just compromise patient safety but raise questions about the breadth and depth of this problem and concerns about “a hidden patient safety problem” totally ignored in some communities.

Professor Samy Azer
Professor of Medical Education
King Saud University

1. Berrier K. Medication Errors in Outpatient Pediatrics. MCN Am J Matern Child Nurs. 2016 Sep-Oct;41(5):280-6. doi: 10.1097/NMC.0000000000000261.

2. Hardenbol AX, Knols B, Louws M, Askari M, Meulendijk M. Usability aspects of medication-related decision support systems in the outpatient setting: A systematic literature review. Health Informatics J. 2018 Nov 30:1460458218813732. doi: 10.1177/1460458218813732. [Epub ahead of print]

3. Koyama T, Onoue H, Ohshima A, Tanaka Y, Tatebe Y, Zamami Y, Shinomiya K, Kitamura Y. Trends in the medication reviews of community pharmacies in Japan: a nationwide retrospective study. Int J Clin Pharm. 2018 Feb;40(1):101-108. doi: 10.1007/s11096-017-0559-7. Epub 2017 Nov 30.

4. Schumacher PM, Neininger MP, Kaune A, Bertsche T. Counseling patients on correct drug handling in German community pharmacies: experiences and opinions of pharmaceutical staff. Int J Clin Pharm. 2018 Nov 29. doi: 10.1007/s11096-018-0757-y. [Epub ahead of print]

Competing interests: No competing interests

07 January 2019
Samy A. Azer
Professor of Medical Education
King Saud University
College of Medicine, Riyadh 11461, Saudi Arabia